Preparing for pregnancy

Large or multiple fibroids may need to be removed. This operation is called a myomectomy. Sometimes it can be done laparoscopically (keyhole surgery). Trying for pregnancy must be delayed for a minimum of 3 months after this surgery, and it may mean that any subsequent deliveries need to be by caesarean section. Tubal damage and scar tissue formation (adhesions) are possible complications.

Fibroids that are inside the womb cavity should always be removed. This surgery is a much less invasive day case procedure called a trans cervical resection of fibroid (TCRF). An IUCD may be inserted at the end of the surgery if more than one fibroid is removed. Patients may normally try to conceive after one to two months. Complications include intrauterine adhesions (scar tissue inside the womb cavity).

Endometriosis affects 1 in 10 women and is more likely when there are other affected family members. It can cause pain, but can be asymptomatic. The disease can cause internal scarring, tubal issues, decreased implantation, and ovulation defects. Sometimes typical ‘chocolate’ cysts form in the ovaries. These can cause progressive destruction of normal ovarian tissue. Women with endometriosis usually have a reduced ovarian reserve (total number of eggs). The condition may be suggested on the basis of painful periods, signs on ultrasound scan, and blood markers, but it can only be confirmed by having a keyhole operation called a laparoscopy. Any endometriosis should be teated surgically when identified. All medical treatments for endometriosis are contraceptive. Pregnancy is one of the best treatments. Once treated, it may recur at any time until the menopause.

Fallopian tubes that are blocked may become swollen with noxious fluid that can trickle into the womb and prevent implantation. Blocked tubes that are swollen enough to be seen on ultrasound scan need to be removed, or opened and clipped. This is a day case keyhole operation called a laparoscopic salpingectomy, or salpingostomy with clipping/sterilisation.

The surgeon will usually prefer to remove the tubes completely, but if there is a lot of scar tissue around them, then simply opening them up to drain the fluid, and clipping the tubes close to the womb to prevent any future fluid accumulation from passing into the womb, is an alternative that is less likely to compromise the very important blood flow to the ovaries. Patients can try to conceive through IVF treatment the following month.

Almost 1 in 50 women are born with an abnormally shaped womb. This may represent anything from a slight dip at the top, making the womb cavity a heart shape instead of a triangle, to a complete division down the middle, a double uterus, or a single half sized version with only one fallopian tube attached (unicornuate uterus). Normal spontaneous pregnancies can occur in any of these shapes but they are much more likely to cause infertility, recurrent miscarriage, and premature delivery. Surgery may be recommended to improve fertiility and reduce pregnancy risk. This surgery is performed as a day case. A telescope called a hysteroscope is inserted through the cervix, and special instruments used to remove septae, or scar tissue from previous surgery. A cervical cerclage (cervical stitch) operation may be recommended for women with uterine abnormalities, even after surgery, in pregnancy to reduce the risk of premature birth.

Sperm are constantly produced by the testicles, and they have to keep moving to stay healthy. This means that when you are trying to conceive, you should ejaculate at least twice a week, so if you are separated from your partner you should masturbate. I recommend having sex once daily (but no more than that) around ovulation. Some couples save up all the sperm for the ovulation day. This is the worst thing you can do, as sperm kept inside for 10 days are more are pretty useless. Having sex for five days in a row around ovulation can get a bit exhausting, especially for the older man or combined with busy work schedules. If this is the case, then use an ovulation kit and try to focus on the 2 big days, but try to also have sex every couple of days from the end of the period.

Many things can potentially affect sperm quality but these are the more common ones:

• Smoking
• Obesity
• Alcohol and all recreational drugs
• Long distance cycling
• Saunas and hot baths
• Sitting for long periods of time eg office workers, taxi drivers
• Exposure to heavy metals and pesticides
• Excessive use of mobile phones
• Anabolic steroids and some body building supplements
• Minoxidil ( Regaine®) - hair loss treatment
• Allopurinol - treatment for gout
• Calcium antagonists (eg nifedipine - Adalat®) - treatment for hypertension / heart failure
• Epilepsy and anti-epileptic medication
• Treatment for inflammatory bowel disease (eg sulphasalazine)
• Antimalarials
• Some antibiotics
• Tight pants
• Fever
• A varicose vein beside the testicle (varicocoele)
• Frequent flights, especially long haul
• Stress

A comprehensive routine sperm test examines a number of parameters that affect sperm function and fertility. Some of these are not included in a basic GP test.

Parameters include:

• an assessment of the supporting fluid - volume, acidity, viscosity, signs of inflammation, blood or infection
• the number of sperm per ml of semen
• the movement of the sperm - how fast are they swimming and in what direction
• the percentage of sperm that do not look perfect - this can actually be up to 96% in fertile men (it is obviously not a very efficient production system!)
• the presence of anti-sperm antibodies - when the immune system reacts to a man's sperm. High levels prevent normal sperm function. There is no known treatment to lower the levels of antibodies. In these cases IVF (ICSI) is often recommended.

There is no such thing as a perfect sperm test! Be prepared when you get the result to be advised that it could always be better!!

A low sperm count can be genetic, but issues with motility and abnormalities are often related to lifestyle factors that can be improved.

If you have a low sperm count, a Doctor should examine you to exclude testicular or prostate cancer, or a varicocoele.

Other more detailed sperm tests that may be recommended include:

• a FISH test - a good idea for men over 40. This looks at the level of chromosome damage in the sperm. If the level of aneuploidy is high, then IVF with genetic testing of embryos is recommended. In some cases, the doctor may discuss the use of donor sperm.
• a ROS test - this gives an indication of the level of harmful free radicals in the semen. These can damage the sperm integrity. High levels are associated with infection, poor diet, excess alcohol, frequent flying, excessive exercise, smoking, heat and chemical exposure (including high levels of air pollution).
• a DNA fragmentation test - to look at levels of DNA damage in the semen. This is important when there is unexplained failure of IVF treatment, or recurrent miscarriage. It may relate to general illness or lifestyle factors.

Impotence can affect any man, of any age, at any time of his life, but the incidence does rise with age. Often it is temporary, related to stress, fatigue or other lifestyle factors, or to relationship issues. In older men in particular, there may be a physical reason for it. In these cases no erections happen, whereas when the issue relates more to emotions or lifestyle, erections can happen, especially during sleep.

Sometimes erections are easy but ejaculation doesn’t happen. This can be a particular issue for men who masturbate to achieve orgasm. Often vaginal intercourse fails to provide enough stimulus. It is sensible to stop masturbating, even when separated from your partner, to try to re-gain the sensation. It might also be useful to think about your orgasm triggers, like pornography or fantasies, and maybe incorporate them into your sex life (within reason!!).

We can chat to you about the issues, or refer you to a urologist for further investigation. We can prescribe viagra or similar drugs to help, but before that, look at your lifestyle and your relationship to see what could be easily improved. Have a think about any medication you are taking. Antidepressants, drugs for anxiety, high blood pressure and heart conditions, can cause impotence. Your doctor may be able to prescribe an alternative.

Its tough for everyone. What started off as a romantic sex fuelled romp to make a baby, becomes a tiresome chore, when pressure to perform ‘on demand’ can be the order of the day. Relationships strain, and feelings of isolation, guilt, inadequacy, embarrassment, anger, frustration, anxiety and depression are common.

There is the possibility that you may be reduced to a hand-holding idiot in an IVF clinic where wanking into a cup pales into insignificance compared to the attention, the daily injections, and an operation to collect the eggs that your partner goes through.

We always listen to both sides of the story, and think about male factors as much as female.

We are your doctor too.

We have fantastic counsellors if things are getting too much, for you, for your partner, or for you both as a couple.

Ovulation induction is recommended when ovulation either doesn’t happen naturally, or is inconsistent. Ideally, both tubes will have been confirmed as being open, and a sperm test reported as normal, before starting. Sometimes, if a tablet version is appropriate, the doctor may be happy for you to regulate your period and ovulation from home for a few months once scans and blood tests have confirmed that it is working, before progressing with other tests.

Women with irregular periods or no periods are suitable candidates for this treatment.

It is usually the first treatment for women with PCOS (polycystic ovaries).

Women who have irregular periods because all their hormone levels are low also need ovulation induction.

Drugs that may be used include:

• daily tablets e.g. Bromocriptine and Metformin
• cyclical tablets (taken day 2-6 of a cycle) e.g. Clomiphene, Letrozole, Tamoxifen
• cyclical injections (taken from day 2 for 9-12 days) e.g. Gonal F®, Menopur®, Meriofert®

The doctor will assess which investigations and medications are required from month to month, and arrange ultrasound scans to check progress (usually 1-2 per month).

All cyclical ovulation induction medication carries the risk of multiple pregnancy, and so usually a low dose is recommended (unless the patient has a low egg count).

Intrauterine insemination may be recommended to improve the chance of pregnancy.

IVF will usually be recommended if appropriate, after 4-6 months of unsuccessful treatment cycles.

This procedure involves selecting the top quality sperm in a semen sample, and putting this sperm up inside the womb cavity just at the time an egg releases. The fast swimmers can get up to the egg through the fallopian tube in a matter of minutes, and the significantly shorter journey (which also avoids potentially unfriendly cervical mucus in the vagina), generally enhances the chance of pregnancy, assuming the overall sperm quality is good, by approximately 5% per cycle.

The technique is also the first treatment choice for couples who are unable to have vaginal sex, and for single women wishing to conceive using donor sperm.

It is rarely recommended for women over 42 years as the success rate is so poor in this group.

Drugs may be given to help grow more than one egg per month and improve success (but only if twins are acceptable).

One to two Ultrasound scans help to identify when the egg is ready.

Blood screening tests are taken from both partners as required for HIV, Hepatitis and Syphilis.

Written consent forms must be completed, both for the clinic, and for the HFEA (Human Fertilisation and Embryology Authority) who regulate this treatment in the UK thus maintaining a high standard of practice in all clinics.

A special injection (Gonasi®, Ovitrelle®) is given when the egg is ripe, to get it ready for release, and 30-36 hours later, the insemination is performed.

A sperm sample is provided after 3 days abstinence, at the fertility clinic. It takes two hours to prepare the super team, i.e. all the funny looking sperm, those swimming backwards or round in circles, and any inflammatory cells, are removed.

The doctor will use a tiny catheter to gently place the prepared sperm right up through the cervix and into the womb cavity. It is a bit like having a smear test, so a bit uncomfortable, but not painful. It takes 10 minutes or so.

You can leave the clinic five minutes later. There is no need to lie down afterwards.

Further treatment may be provided after the insemination to help implantation, and for couples, we suggest having sex that night too.

A pregnancy test is performed after 14 days.